Acute sensory neuropathy in an adolescent girl following BCG vaccination

Guillain Barré syndrome associated with bladder instillation of Bacille Calmette Guérin (BCG)

Introduction.

Guillain Barré Syndrome (GBS) has rarely been associated with tuberculosis and has been previously reported after Bacille Calmette Guérin (BCG) vaccination, but we report an association of GBS with intra-vesical BCG instillations followed by the clinical picture of disseminated BCGosis.

Case presentation.

A 68-year-old man with bladder carcinoma had a transurethral tumour resection followed by repeated BCG instillations. Catheterization for his eighth dose was traumatic, causing frank haematuria. Ten days later he presented with fevers, myalgia and dyspnoea. Chest X-ray on admission showed micronodular shadowing and a computed tomography scan showed miliary changes in the lungs. Disseminated BCGosis infection was suspected and his symptoms did improve after starting rifamipicin, isoniazid and ethambutol. Over 2 weeks post-admission he developed an unsteady gait, reduced pin-prick sensation below both knees and fingertips, reduced proprioception in both toes and ankles, with absent reflexes in his lower limbs and diminished reflexes in his upper limbs. Nerve conduction studies showed a purely demyelinating sensori-motor peripheral neuropathy in upper and lower limbs, characteristic of GBS.

Conclusion.

To our knowledge this is the first case report of GBS following bladder instillation of BCG. Given the millions of cases of tuberculosis and millions of doses of administered BCG, GBS must be a very rare adverse effect.

Possible association of Guillain-Barré syndrome and hepatitis A vaccination

We report a case of Guillain-Barré syndrome in a previously healthy child who received a hepatitis A vaccination (HAVRIX) 5 days before onset of symptoms. No other precipitating factor could be identified. The relevant literature is reviewed and discussed.

Pathogenesis of Guillain-Barré syndrome

Recent neurophysiological and pathological studies have led to a reclassification of the diseases that underlie Guillain-Barré syndrome (GBS) into acute inflammatory demyelinating polyradiculoneuropathy (AIDP), acute motor and sensory axonal neuropathy (AMSAN) and acute motor axonal neuropathy (AMAN). The Fisher syndrome of ophthalmoplegia, ataxia and areflexia is the most striking of several related conditions. Significant antecedent events include Campylobacter jejuni (4-66%), cytomegalovirus (5-15%), Epstein-Barr virus (2-10%), and Mycoplasma pneumoniae (1-5%) infections. These infections are not uniquely associated with any clinical subtype but severe axonal degeneration is more common following C. jejuni and severe sensory impairment following cytomegalovirus. Strong evidence supports an important role for antibodies to gangliosides in pathogenesis. In particular antibodies to ganglioside GM1 are present in 14-50% of patients with GBS, and are more common in cases with severe axonal degeneration associated with any subtype. Antibodies to ganglioside GQ1b are very closely associated with Fisher syndrome, its formes frustes and related syndromes. Ganglioside-like epitopes exist in the bacterial wall of C. jejuni. Infection by this and other organisms triggers an antibody response in patients with GBS but not in those with uncomplicated enteritis. The development of GBS is likely to be a consequence of special properties of the infecting organism, since some strains such as Penner 0:19 and 0:41 are particularly associated with GBS but not with enteritis. It is also likely to be a consequence of the immunogenetic background of the patient since few patients develop GBS after infection even with one of these strains. Attempts to match the subtypes of GBS to the fine specificity of anti-ganglioside antibodies and to functional effects in experimental models continue but have not yet fully explained the pathogenesis. T cells are also involved in the pathogenesis of most or perhaps all forms of GBS. T cell responses to any of three myelin proteins, P2, PO and PMP22, are sufficient to induce experimental autoimmune neuritis. Activated T cells are present in the circulation in the acute stage, up-regulate matrix metalloproteinases, cross the blood-nerve barrier and encounter their cognate antigens. Identification of the specificity of these T cell responses is still at a preliminary stage. The invasion of intact myelin sheaths by activated macrophages is difficult to explain according to a purely T cell mediated mechanism. The different patterns of GBS are probably due to the diverse interplay between antibodies and T cells of differing specificities.